Osteoporosis treatment combines medication, nutrition, and exercise to slow bone loss, rebuild bone density, and prevent fractures. The specific approach depends on how severe your bone loss is, your age, and your estimated fracture risk over the next 10 years. Most people with osteoporosis will use at least one prescription medication alongside calcium, vitamin D, and regular weight-bearing exercise.
Who Needs Medication
Not everyone with lower bone density needs prescription treatment. Doctors use a fracture risk calculator called FRAX to estimate your 10-year probability of breaking a bone. This tool factors in age, sex, weight, smoking history, alcohol use, prior fractures, and bone density measurements. The threshold for recommending medication rises with age. For example, a 60-year-old with a 12.2% or higher 10-year probability of a major osteoporotic fracture would typically be offered treatment, while a 70-year-old’s threshold sits around 20.3%.
If you’ve already had a fragility fracture (a break from a fall at standing height or less), medication is generally recommended regardless of your FRAX score. The same applies if your bone density scan shows a T-score of -2.5 or lower at the hip or spine.
Medications That Slow Bone Loss
The most widely prescribed osteoporosis drugs work by slowing down the natural process of bone breakdown. Your skeleton constantly recycles itself: old bone is removed and new bone is deposited. In osteoporosis, removal outpaces replacement. These “anti-resorptive” medications tip the balance back toward preservation.
Bisphosphonates are the most common starting point. Alendronate (Fosamax) is taken as a weekly pill, while zoledronic acid (Reclast) is given as an intravenous infusion, typically once a year. Oral bisphosphonates can also be taken daily or monthly depending on the specific drug. They strengthen bones and reduce the risk of fractures in the spine, hip, and wrist. The oral forms need to be taken on an empty stomach with a full glass of water, and you have to stay upright for at least 30 minutes afterward to avoid throat and stomach irritation.
Denosumab (Prolia) takes a different approach. It blocks a protein that bone-dissolving cells need to form and survive. It’s given as an injection under the skin every six months. One critical thing to know about denosumab: you cannot simply stop taking it. After discontinuation, bone turnover surges above pre-treatment levels within about nine months, and your fracture risk jumps significantly, including the risk of multiple spinal fractures. If you miss or delay a dose, get it as soon as possible and resume the six-month schedule from that date.
Medications That Build New Bone
While the drugs above protect what you have, a second category actively stimulates new bone formation. These are called anabolic agents, and they’re generally reserved for people at highest fracture risk or those who’ve already fractured while on other treatments.
Teriparatide and abaloparatide are both daily self-injections that mimic a hormone involved in bone building. In high-risk postmenopausal women, abaloparatide reduced new spinal fractures by 85% compared to placebo over 18 months. It also produced significant bone density gains at the spine, hip, and femoral neck at every measured time point. Major osteoporotic fractures dropped from 6.8% in the placebo group to 1.6% in the treatment group.
Romosozumab works differently, blocking a protein that normally puts the brakes on bone formation. It’s given as a monthly injection for one year. These bone-building drugs are typically used for a limited time (12 to 24 months) and then followed by an anti-resorptive medication to maintain the gains.
Hormone-Based Options
For women in early menopause, hormone replacement therapy can help preserve bone density because estrogen plays a direct role in maintaining bone strength. It’s most often considered when a woman also needs relief from hot flashes and other menopausal symptoms, making it a two-for-one treatment rather than a standalone osteoporosis drug.
Raloxifene is a selective estrogen receptor modulator that acts like estrogen on bone tissue while blocking estrogen’s effects on breast tissue. It may reduce the risk of spinal fractures in postmenopausal women and is sometimes preferred for women who are also at increased risk of breast cancer. It does not, however, protect against hip fractures as effectively as bisphosphonates.
How Long Treatment Lasts
Osteoporosis treatment is not a short course. Most people take bisphosphonates for three to five years before their doctor reassesses the situation. At that point, some people qualify for a “drug holiday,” a planned pause in treatment. This isn’t an option for everyone.
If your 10-year fracture risk is below 10% after treatment, stopping the medication is reasonable. If your risk is moderate (10 to 20%), a holiday may be considered only if you have no history of fragility fractures and your hip bone density T-score has improved to better than -2.5. If you’re high risk, with a prior hip or spinal fracture or a 10-year risk above 20%, the recommendation is to continue treatment or switch to a different agent. During a drug holiday, your doctor will monitor your bone density and may restart treatment if it declines.
Calcium and Vitamin D
Every osteoporosis treatment plan includes adequate calcium and vitamin D, because medications work best when your body has the raw materials to build bone. For postmenopausal women, the target is 1,200 mg of calcium per day from food and supplements combined, plus 800 IU of vitamin D. For premenopausal women and men, 1,000 mg of calcium and 600 IU of vitamin D is generally sufficient.
Food sources are preferred over supplements when possible. A cup of milk or fortified plant milk provides roughly 300 mg of calcium. Yogurt, cheese, canned sardines with bones, fortified orange juice, and leafy greens like kale also contribute. If your diet falls short, a supplement can fill the gap, but taking more than 500 to 600 mg of supplemental calcium at once reduces absorption. Splitting doses across the day is more effective.
Exercise for Bone Strength
Weight-bearing and resistance exercises are essential, not optional, parts of osteoporosis management. They stimulate bone-forming cells and improve the muscle strength and balance that prevent falls in the first place.
Four types of exercise matter most:
- Weight-bearing aerobic activity: walking, dancing, low-impact aerobics, stair climbing, elliptical training, and gardening. These force your bones to support your body weight against gravity.
- Strength training: free weights, resistance bands, or bodyweight exercises. Upper back exercises are especially valuable because they counter the rounded posture that spinal fractures can cause. One set of 12 to 15 repetitions per exercise is a reasonable starting point.
- Balance exercises: standing on one leg, heel-to-toe walking, and tai chi. These directly reduce fall risk.
- Flexibility exercises: gentle stretching to maintain range of motion and reduce stiffness.
Swimming and cycling, while great for cardiovascular health, don’t load the skeleton enough to stimulate bone growth. They’re fine additions to a routine but shouldn’t be the only activities you do.
Rare but Serious Side Effects
The most discussed risks of long-term anti-resorptive therapy are jaw problems and unusual thigh fractures. Osteonecrosis of the jaw is a condition where a section of jawbone loses its blood supply and begins to break down. In osteoporosis patients taking standard doses, this is uncommon. The risk is substantially higher in cancer patients receiving much larger doses of these same drugs, where studies have found rates of 3% with bisphosphonates and 12% with denosumab. At the lower doses used for osteoporosis, the risk is a small fraction of those numbers, but good dental hygiene and completing any needed dental work before starting treatment helps reduce it further.
Atypical femur fractures, breaks in the thigh bone that occur with minimal trauma, are another rare complication associated with very long-term bisphosphonate use. This is one reason doctors reassess treatment after three to five years. Unexplained thigh or groin pain while on these medications warrants prompt evaluation.